GMH: the concept

The term ‘Global Mental Health’ (GMH) may seem self-explanatory; however, it is a carefully chosen phrase, and stands in opposition to previous descriptors as well as other possible alternatives. The term ‘global’ has replaced outmoded words such as ‘tropical’, and even the more recent concept of ‘international’ health. This is partly a political statement, implying that anyone with mental illness anywhere on the globe deserves attention, regardless of race, creed, caste or location (Kirmayer & Pedersen, Reference Kirmayer and Pedersen2014). Invocation of the word ‘global’, also associates GMH with other inspirational statements of the ‘global’, for example the Universal Declaration of Human Rights (Kleinman, Reference Kleinman2009). Indeed GMH draws much inspiration and support from another ‘global’ body, the World Health Organization (WHO, 2010, 2013; Saxena et al. Reference Saxena, Funk and Chisholm2013). Relatedly, the term ‘mental health’ has been carefully chosen instead of ‘psychiatry’. This makes the endeavour more inclusive, implicitly acknowledging that other academic disciplines can play a role in furthering GMH (Patel, Reference Patel2014).

It is important to note that GMH is much more than a rarefied academic concept. It is also a movement with proponents, adherents, opponents, an ideology and core activities. Like all movements, it has leaders, meetings, publications, websites and a level of organisation allowing it to function and expand. The birth of the GMH movement can be traced to London, 2007, when researchers led by Vikram Patel (London School of Hygiene and Tropical Medicine) and Martin Prince (King's College London) published a series of papers in The Lancet on the topic (Chisholm et al. Reference Chisholm, Flisher, Lund, Patel, Saxena, Thornicroft and Tomlinson2007; Patel et al. Reference Patel, Araya, Chatterjee, Chisholm, Cohen, De Silva, Hosman, McGuire, Rojas and van Ommeren2007a , Reference Patel, Flisher, Hetrick and McGorry b ; Prince et al. Reference Prince, Patel, Saxena, Maj, Maselko, Phillips and Rahman2007). Indeed Lancet editor Richard Horton titled his commentary ‘launching a new movement for mental health’ (Horton, Reference Horton2007).

This was accompanied by other outreach efforts, including the formation of an official ‘movement for GMH’, consisting of various university departments and other organisations (Patel et al. Reference Patel, Collins, Copeland, Kakuma, Katontoka, Lamichhane, Naik and Skeen2011c ). This is described at www.globalmentalhealth.org. The stated aims of the Movement for GMH are ‘to improve services for people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income countries where effective services are often scarce’. This aim distinguishes the GMH movement from the decades of work within cultural psychiatry and medical anthropology that sought to understand local conceptions of mental distress and healing (Kirmayer & Pedersen, Reference Kirmayer and Pedersen2014).

GMH: the rationale

The rationale for the new GMH movement derives from various sources. Historically, it derives from a cognizance that throughout the history of the developing world, addressing mental illness has been accorded a very low priority. In the colonial era, formal health care was unjustly distributed, often focused on ensuring the health and well-being of colonial administrators and European settlers. The health care of the indigenous population was a secondary interest to the medical establishment, unless it endangered white hegemony or social stability (Hickling, Reference Hickling1994).

Despite independence, the neglect of mental health issues persisted during the post-colonial era. Mental health policies and practices remained stagnant, partially due to other pressing problems. These included war, natural disasters, infectious disease epidemics, famine and drought. As such, much governmental and non-governmental action was focused on addressing these problems. Again mental health remained a peripheral issue. As such, GMH could be considered an effort to right a persistent historic wrong: the continued neglect of mental illness in developing countries; what Kleinman (Reference Kleinman2009) calls ‘a failure of humanity’.

Relatedly, it should be noted that the Western psychiatric establishment of the day either supported such neglect or was at best indifferent to mental illness in the non-Western world. Much contemporary psychiatric ‘scholarship’ (and popular opinion) depicted mental illness as a disease caused by maladaptation to ‘civilisation’ and modernity (Freud, Reference Freud1930; Gordon, Reference Gordon1936; Jung, Reference Jung1964). As such, it was commonly believed that Africans and other non-Western people were protected from mental illnesses due to the posited absence of civilisation therein. Indeed Carothers (Reference Carothers1953) famously stated that ‘the African is a happy savage’ protected from psychic conflict due to an untamed environment and inexperience of modernity. Such environmental explanations interacted with biological scientific racism, with Carothers (Reference Carothers1951) stating that Africans had ‘idle’ frontal lobes which made them less susceptible to mental illness.

This neglect continued into the 21st century, as health advocates continued to concentrate their efforts on reducing the burden of communicable disease, focusing their energy on vaccinations, improved sanitation and infectious disease control. This led to improvements in public health allowing a substantial proportion of these countries to make the epidemiological transition in recent years. This has led to an increased burden of non-communicable disease as a proportion of the total disease burden (Alonso et al. Reference Alonso, Chatterji and Yanling2013). As a consequence, mental illness, for so long neglected as a peripheral medical concern, has taken a new prominence.

The GMH problem: the ‘treatment gap’

Proponents of GMH have relied on pre-existing studies to define the core GMH problem, which has been succinctly defined in three words: ‘the treatment gap’ (Patel et al. Reference Patel, Maj, Flisher, De Silva, Koschorke and Prince2010). This is an estimate of the proportion of people with a supposed mental illness who are actually receiving formal mental health treatment, estimated to be between 10 and 25% (Patel et al. Reference Patel, Maj, Flisher, De Silva, Koschorke and Prince2010; WHO, 2011). In particular, the foundation of GMH is based on numerous studies that converge to indicate that: (i) the burden of mental illnesses such as schizophrenia in developing countries are roughly equal to those found in Western countries, and increasing as a proportion of total disease burden (WHO, 2011; Alonso et al. Reference Alonso, Chatterji and Yanling2013); (ii) the vast majority of these mental illnesses go untreated by the formal mental health system (Patel & Prince, Reference Patel and Prince2010); (iii) in response to mental health issues, many sufferers resort to traditional or spiritual healers and healing (Kleinman, Reference Kleinman1980; de Jong, Reference de Jong2014); (iv) the impact of mental illness in these settings can be devastating, in terms of symptoms, stigma and functional impairment (Prince et al. Reference Prince, Patel, Saxena, Maj, Maselko, Phillips and Rahman2007); (v) the availability and penetration of formal mental health treatment, and the ratio of mental health clinicians to the population, remain exceedingly low (Kakuma et al. Reference Kakuma, Minas, van Ginneken, Dal Poz, Desiraju, Morris, Saxena and Scheffler2011). This results in a substantial ‘treatment gap’.

This knowledge was the departure point for the GMH movement, leaving it free to focus its energy on raising awareness of the treatment gap and developing solutions. This has been done through a series of audacious steps. In addition to the 2007 Lancet series, key figures have continued to publish regular papers in prominent journals outlining the GMH agenda and calling for more action. This includes further articles in The Lancet (e.g., Patel et al. Reference Patel, Boyce, Collins, Saxena and Horton2011a ), Nature (Collins et al. Reference Collins, Patel, Joestl, March, Insel, Daar, Anderson, Dhansay, Phillips, Shurin, Walport, Ewart, Savill, Bordin, Costello, Durkin, Fairburn, Glass, Hall, Huang, Hyman, Jamison, Kaaya, Kapur, Kleinman, Ogynniyi, Otero-Ojeda, Poo, Ravindranath, Sahakian, Saxena, Singer and Stein2011) and JAMA (Patel & Prince, Reference Patel and Prince2010). Secondly, funding agencies have been persuaded to lend substantial financial support to GMH action and research initiatives through specific funding opportunities. These include funding streams made available by Grand Challenges Canada, the Wellcome Trust, the U.K Department for International Development (DfID) and the U.S. National Institutes of Health (Patel, Reference Patel2012; Bemme & D'Souza, Reference Bemme and D'Souza2014). Thirdly, a broad alliance of interested parties across the world has been formed and solidified to address GMH issues (see www.globalmentalhealth.org). As a movement, GMH has been phenomenally successful in promoting its agenda and gaining visibility in a relatively short space of time.

The GMH solution: scale-up and task-shifting

Given that GMH is still in its infancy, its amassed empirical work remains modest in comparison with other areas of psychiatry, with many of its key papers being editorials rather than research studies (e.g., Prince et al. Reference Prince, Patel, Saxena, Maj, Maselko, Phillips and Rahman2007; Collins et al. Reference Collins, Patel, Joestl, March, Insel, Daar, Anderson, Dhansay, Phillips, Shurin, Walport, Ewart, Savill, Bordin, Costello, Durkin, Fairburn, Glass, Hall, Huang, Hyman, Jamison, Kaaya, Kapur, Kleinman, Ogynniyi, Otero-Ojeda, Poo, Ravindranath, Sahakian, Saxena, Singer and Stein2011). That said, a respectable amount of empirical work has been conducted since 2007. Much of this has focused on developing and evaluating systems or interventions that can address the ‘treatment gap’.

The most oft-cited potential solution to this problem has become known as the ‘scale-up’ of evidence based practices and services in developing countries. This involves identifying cost-effective evidence-supported practices and services that could feasibly be made more widely available in developing countries (Chisholm et al. Reference Chisholm, Flisher, Lund, Patel, Saxena, Thornicroft and Tomlinson2007). The WHO took a lead in this process through its Mental Health Gap Programme, which published an intervention guide for ‘mental, neurological and substance use disorders in non-specialised health settings’ based on extensive literature review (WHO, 2010). This gave guidance for the treatment of disorders in developing countries, including depression, psychosis and bipolar disorder, suggesting pharmacological as well as psychosocial interventions.

Such activity begs a further question, namely, who is going to deliver such interventions given the paucity of personnel trained in mental health care in developing countries? This has involved widespread examination of what has become known in the literature as ‘task-shifting’. Task-shifting involves training locally based non-specialists to deliver certain mental health interventions, mainly psychosocial ones or ‘talking therapies’ (Fulton et al. Reference Fulton, Scheffler, Sparkes, Auh, Vujicic and Soucat2011). These non-specialists are generally Lay Health Workers (LHWs). These are local community health workers with some health training, ubiquitous across the developing world. Numerous studies, including several completed and ongoing randomised controlled trials, have examined the ability of specially trained LHWs to effectively deliver interventions such as Cognitive Behavioural Therapy or Interpersonal Psychotherapy (Rahman et al. Reference Rahman, Malik, Sikander, Roberts and Creed2008; Patel et al. Reference Patel, Chowdhary, Rahman and Verdeli2011b ). Key findings from such studies are that ‘task-shifting’ to LHWs is not only feasible, but also effective. Trial results consistently showed significantly better recovery rates in the intervention group than those receiving a psychosocial placebo (unstructured LHW visits).

Efforts have also been made to develop and outline suitable training programmes and desirable competencies for LHWs, as well as common deficiencies that need to be addressed (Fulton et al. Reference Fulton, Scheffler, Sparkes, Auh, Vujicic and Soucat2011; Balaji et al. Reference Balaji, Chatterjee, Koschorke, Rangaswamy, Chavan, Dabholkar, Dakshin, Kumar, John, Thornicroft and Patel2012). So far, growing evidence about effective task-shifting of psychosocial interventions to LHWs could be considered the major research finding of the GMH enterprise.

GMH: the critique

GMH has come under a sustained attack from a variety of scholars. Much like the anti-psychiatry attack in the 1960s, this attack has come most vociferously from other psychiatrists (rather than the oft-blamed social scientists) such as Derek Summerfield and Suman Fernando.

A central critique is that GMH activities are aggressively and erroneously imposing the Western model of mental illness on the entire globe in a top-down manner. This has been interpreted as an act of cultural imperialism reminiscent of colonial era ‘tropical medicine’ where indigenous knowledge and practice was ridiculed and marginalised (Summerfield, Reference Summerfield2008, Reference Summerfield2013; Fernando, Reference Fernando2011). It is also claimed that this is scientifically invalid, inasmuch as Western concepts of mental illness are posited to be cultural constructs inapplicable elsewhere (Summerfield, Reference Summerfield2002). This argument also claims that GMH elides the various modalities of healing present in non-Western cultures, which may be psychologically adaptive and curative (Sax, Reference Sax2014).

For example, much care of people with psychological troubles in developing countries is provided within the family, a spiritual community or by traditional healers (Kleinman, Reference Kleinman1980). As a consequence, the process of labelling and separation of people with ‘mental illness’ from wider society, so detrimental to recovery and social integration in the west, appears less pronounced in developing countries. Indeed, much evidence suggests that these inclusive processes have a strong curative and therapeutic value. Results from the well-known International Pilot Study of Schizophrenia show that functional outcomes (such as employment) and recovery rates are better in developing countries than the developed world (Leff et al. Reference Leff, Sartorius, Jablensky, Korten and Ernberg1992). This has been partially attributed to international variations in the nature and degree of stigma and separation (Thara & Srinivasan, Reference Thara and Srinivasan2000; Hopper et al. Reference Hopper, Harrison, Janca and Sartorius2007). This suggests that traditional modalities of healing involving the family, social normalisation and spiritual approaches may play an important role in recovery. However, spirituality, traditional healers and traditional healing approaches are generally absent in the GMH literature and agenda, which focuses on neatly packaged Western-derived pharmacology or psychosocial interventions (Fernando, Reference Fernando2012).

This relates to another critique. This is the fear that GMH could be an unwitting Trojan horse for the mass medicalisation of people in the developing countries, paving the way for corporate interests (i.e., ‘Big Pharma’) to repackage social suffering as a medical problem and exploit potential new markets (Fernando, Reference Fernando2011). This argument runs as follows: firstly, alien concepts and categories such as post traumatic stress disorder (PTSD) or depression are introduced into new places; secondly, people who were previously categorised as having manageable ‘problems in living’ are identified and relabelled as ‘mentally ill’; thirdly, these people are then offered medications developed in the Western world. This concern is fuelled by the fact that the WHO MHGap Programme recommends a strong role for psychotropic medication in the developing world (WHO, 2010).

In response, GMH leaders such as Patel (Reference Patel2014) claims that this argument basically traduces GMH, inasmuch as most GMH interventions hitherto have been psychosocial or talking therapies. Patel (Reference Patel2014) also states that ‘I have never received personal funding from any pharmaceutical company’. That said, GMH is clearly a top-down elite-led movement rather than a bottom-up grassroots movement, formed and led by Western-educated clinicians (Bemme & D'Souza, Reference Bemme and D'Souza2014). The overlap between their preferred models and interventions and those of ordinary people on the ground continues to be questioned in the literature (Swartz, Reference Swartz2012).

Another critique relates to the nature of ‘partnerships’ in GMH. Crane (Reference Crane2011, Reference Crane2013) and others have argued that global health in general is not based on a true collaborative partnership between north and south. In contrast, she argues that Western universities and NGOs are engaged in a somewhat undignified ‘scramble for Africa’ for reasons of prestige, public relations and competition with other Western universities. Short-term medical missions, study abroad programmes, university partnerships, student internships and the like provide ample opportunity for students and faculty from Western universities to travel and bring honour to their home universities. However, Crane (Reference Crane2011, Reference Crane2013) notes that these programmes are often unidirectional and questions how far they benefit the communities they aim to serve.

A final critique relates to the social and cultural determinants of health. It has been argued that GMH is anthropologically and sociologically naïve, inasmuch as a considerable amount of the social and mental suffering experienced in developing countries can be attributed to adverse social conditions, structural violence, poverty, war, famine and inequality (Kirmayer & Pedersen, Reference Kirmayer and Pedersen2014). Summerfield (Reference Summerfield2008) argues that the natural human response to such phenomena is a level of everyday social suffering that may superficially appear like ‘depression’ but is in fact not a mental illness but ‘a normal reaction to their circumstances’ (p 993). Rather than focusing attention on the causes of such social suffering, GMH is perceived to be providing medical solutions to non-medical problems, thereby unwittingly acquiescing in the social status quo. In response, Patel (Reference Patel2014) argues that many GMH interventions include attention to social conditions, including addressing livelihood skills as well as raising awareness about rights and community resources.

That said, it is worth noting that GMH has avoided the critical or radical post-colonial tradition in psychiatry which argues that much social suffering and emotional distress is based on social and ethnic hegemony and domination, which must be combatted to improve mental health (e.g., Fanon, Reference Fanon1952, Reference Fanon and Farrington1963; Grier & Cobbs, Reference Grier and Cobbs1968; Welsing, Reference Welsing1991). Even in Western countries, much attention has been given to the negative health impact of social stratification and inequality (Marmot, Reference Marmot2005; Wilkinson & Pickett, Reference Wilkinson and Pickett2006). This is also a tradition within wider public health and epidemiology research (e.g., Farmer, Reference Farmer2004; Tol et al. Reference Tol, Rees and Silove2013). Indeed, a recent editorial in The Lancet (2014) noted that health advocates have avoided confronting uncomfortable truths in developing countries such as the ‘institutionalised inequality’ of the Indian caste system and its deleterious effect on the health of ‘low-caste’ people. Controversial issues such as these, in addition to issues such as sectarianism, war, racism and social elitism, have been avoided by GMH, which has preferred to focus its activities on the scale-up and task-shifting of narrow, Western-developed interventions (Summerfield, Reference Summerfield2012).

The discipline of medical anthropology provides one approach to link social, economic and political forces to local experiences of (individual and social) suffering and distress (Janes & Corbett, Reference Janes and Corbett2009). Intensified partnerships between medical anthropologists and GMH leaders (most of whom are trained psychiatrists) may be a fruitful approach to resolve these issues.